This book sets out to prove that an epidemic
of insanity has taken place over recent centuries. It argues that a
"plague of brain dysfunction" has occurred largely unnoticed. The
implication is that the asylums should not have been emptied without ensuring
adequate treatment to control the epidemic. Believing that insanity has always
been with us in its present form is said to be a fundamental misunderstanding
of its essence.

Historical
material is analysed to suggest that insanity was not a major problem in the
seventeenth century. Records, including literary works, from England, Ireland,
Canada and the United States are considered to demonstrate that the rising
incidence of insanity started to be of concern at the end of the eighteenth
century. The official view was that the disproportionate increase in the number
of people confined in asylums compared to the population increase was only an
"apparent" rather than a real increase in insanity. The book prefers
instead the more straightforward, popular view that epidemic insanity is
genuine.

"Anti-psychiatry" is blamed for
neutralizing the issue of epidemic insanity by arguing that mental illness does
not exist. Historians of psychiatry who point out that the availability of
institutional facilities encouraged increasing confinement are dismissed. As
far as the book is concerned, asylums were not built for social or economic
reasons, but merely to respond to the epidemic. The prevalence of insanity
since the middle of the twentieth century is said to be unclear, because dehospitalization
and the move to community care have made accurate counts more difficult. In
fact, the indications are said to point to a continuing increase, at least in
Canada and the United States.

The book's thesis is that a concomitant
factor of industrialisation and urbanisation must have caused the increase in
insanity. Stress is excluded as a possible factor as there is said to be no
evidence that stress causes insanity and, contrary to expectations, the World
Wars and Great Depression did not produce an increase in severe psychiatric
disorders. Further research is suggested to look for correlations with diet,
improved obstetrical care, toxins and infectious agents, amongst other factors.

The book makes the assumption that
schizophrenia and manic-depression are brain diseases. The rest of its thesis
follows naturally. If insanity is entirely physical, uninfluenced by social
factors, then the increase in numbers of people identified as insane must be real.

Such a proposition flies in the face of the
facts. Psychiatric diagnosis may at least be unreliable and possibly at times
invalid. Psychiatric practice is about social control, even if diagnoses are
based on individual factors. Understanding the reasons for mental health
problems is not helped by postulating brain pathology as their cause.

Although the book's perspective that social
and cultural factors are totally irrelevant is extreme, research has
consistently underestimated their importance. For example, it is commonly
stated that the incidence of schizophrenia is the same the world over, ignoring
variations in the presentation of symptomatology. Furthermore, outcome is
variable across the world, at least influenced by treatment differences.

In Japan,
the number of in-patients hasincreased from the 1950s, while that
of England has decreased. Most Japanese
in-patients are admittedcompulsorily, whereas most are admitted
informally in England. Does the Japanese data disprove the book's hypothesis,
or is it evidence that the people in Japan have been exposed more recently to
the same physical factors associated with industrialisation and urbanisation
that caused insanity earlier in the developed world?

I enjoyed the literary references in the
book. I did not take pleasure in much else and was annoyed by its speculations.
I accept there are difficulties in deciding the legitimacy of biological causes
of mental illness, but this book regards physical pathology as the proven basis
for mental illness. Admittedly, much of psychiatric thinking agrees with this
conjecture. In some ways, this book is more consistent in excluding a role for
psychogenesis altogether, whereas mainstream psychiatry does recognise a stress‑diathesis.

I am sure that mental health
problems have changed over the years and that mental illness is part of the
human condition. Otherwise, I seem to be coming at the issues raised by the
book from the polar opposite direction. I do not think the social role of
psychiatry can be avoided. To argue that the rise of the asylum reflected a
brain illness epidemic is trite and simplistic. In my view, the book is not a
scholarly historical study. Don't read it, unless you are interested in its
prejudices.

Our book is, indeed, based on the assumption that schizophrenia
and bipolar disorder are diseases of the brain, just as are Parkinsons
disease and Alzheimers disease. The evidence for this is overwhelming,
and it is unusual now to find a psychiatrist who questions this fact.
Social and cultural factors may influence the expression of psychotic symptoms
and the relative availability of hospital beds, but they do not influence
the incidence of schizophrenia any more than they influence the incidence
of Parkinsons disease.

E. Fuller Torrey, M.D.
Judy Miller

Duncan Double responds: July 18, 2002:

I am pleased the authors have confirmed that I have understood
their book. I agree that it is unusual for psychiatrists to question the
hypothesis that mental illness is caused by brain pathology. Such a view
is almost heretical in the state of modern psychiatry, which I think should
be of concern for society as a whole. The Critical
Psychiatry Network does not believe that psychiatric practice needs
to be justified by postulating brain pathology as the basis for mental
illness.

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